Medicaid Contract Purchasing SpecificationsPart 2Enrollment and Disenrollment ProceduresTable of Contents §201. Enrollment In General If, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language on enrollment is for your consideration. §201. Enrollment In General K(a) Children Receiving Treatment at the Time of Enrollment — Contractor shall comply with the requirements of §202. K(b) Newborns — Achild born to a woman who is enrolled with Contractor and who is eligible for [drafter insert name of State's Medicaid Program] shall be deemed to be an enrolled child under [drafter insert name of purchasing document] from the time of birth until: (1) Purchaser has notified Contractor that the child is ineligible for [drafter insert name of State's Medicaid Program]; or (2) the child has been disenrolled by child's family or caregiver.
K§202. Duties Related to Children Receiving Treatment at the Time of Enrollment Commentary: The following illustrative language addresses Contractor's duties related to children receiving treatment at the time of enrollment. The duties will have implications both for the children and for other state agencies with program responsibilities for those children. The provisions set forth policy options Purchasers may want to consider in addressing the on-going treatment needs of an enrolled child as he/she enters into a managed care plan. For example, Contractor may continue to furnish the items and services under the original treatment plan, or may undertake an alternate treatment based on a medical evaluation by a network provider. Purchasers may wish to consider adjusting their premium payments to reflect additional costs if Contractor implements the original treatment plan. (a) Children with Certain Reportable Diseases — In the case of a child with respect to whom [drafter insert name of state or local public health agency or agencies with jurisdiction] has issued a treatment plan regarding [drafter insert names of relevant reportable diseases] under [drafter insert reference to applicable state law] prior to the child's enrollment, Contractor shall, upon the child's enrollment:1 (1)cover and furnish, or arrange for the furnishing of, the items and services that are specified in the treatment plan (whether or not such items and services are covered under Part 1) until: (A) the enrolled child's primary care provider has: (i) fully implemented the treatment plan; or (ii) on the basis of a medical evaluation, undertaken alternate treatment for the disease that is set forth in writing in the enrolled child's medical record; (2) notify the agency that issued the treatment plan, in such form and manner as the agency shall specify under [drafter insert reference to memorandum of agreement implementing §702(d) of Part 7], of Contractor's progress in implementing the treatment plan (or alternate treatment undertaken by the enrolled child's primary care provider) and the status of the enrolled child's disease. Commentary: In a May 21, 1999, letter to State Medicaid Directors, HCFA reaffirms that "Medicaid is the payer of first resort for medical services provided to children with disabilities pursuant to the Individuals with Disabilities Education Act (IDEA)." The following illustrative language, like the illustrative language at §105A (relating to coordination of benefits), assumes that the state Medicaid agency has contracted with the MCO to furnish or arrange for the furnishing of all items and services covered under the state Medicaid plan. Of course, a state Medicaid agency is not required to contract with an MCO for the provision of all Medicaid items and services; however, the agency remains responsible for coverage of those items and services "carved out" of the MCO contract to which children with disabilities are entitled. However, if school-based services are carved out of the contract, the contract should include specfications relating to the coordination between the school and contractor in order to avoid duplication of services and payment. (b) Children Under an IEP or IFSP — In the case of a child (including an adolescent) who at the time of enrollment is receiving services under an Individualized Education Program (IEP) (as defined in §1401(o)) or an Individualized Family Services Plan (IFSP) (as defined in §1401(p)), Contractor shall, consistent with §1903(c) of the Social Security Act, 42 U.S.C. §1396b(c), cover and furnish, or arrange for the furnishing of, the items and services enumerated in the IEP or IFSP that are covered under Part 1.2 (c) Children Receiving Treatment for Other Conditions — In the case of a child (including an adolescent) who is not described in subsection (a) or (b) and who at the time of enrollment is under treatment for any physical or mental illness, condition, or disability, Contractor shall continue to furnish items and services covered under Part 1 to the child which are being furnished as part of the child's treatment unless: (1) a provider participating in Contractor's provider network who has assumed responsibility for care of the enrolled child has, on the basis of a medical evaluation of the child, determined in accordance with §§101A and 102A of Part 1A that an item or service is no longer medically necessary; and (2) Purchaser concurs in the providers determination under paragraph (1) (which is sought from Purchaser by the child or the child's family or caregiver).
§203. Disenrollment In General
K(a) Permissible Grounds for Disenrollment at Request of Contractor — Contractor may request that Purchaser disenroll an enrolled child eligible under [drafter insert name of State's Medicaid program] only if: (1) Purchaser has notified Contractor that the child is no longer eligible for [drafter insert name of State's Medicaid program]; (2) the enrolled child has elected to disenroll: (A) during the 90-day period described in subsection (b)(1); or (B) at the end of the one-year period described in subsection (b)(2); and (3) the enrolled child has elected to disenroll as a right under subsection (b) or for cause under subsection (c). (b) Enrolled Child's Right to Disenroll Without Cause L(1) 90-Day Period — Contractor agrees that, as authorized by §1903(m)(2)(A)(vi) (I) and §1932(a)(4)(A)(ii)(I) of the Social Security Act, 42 U.S.C. §1396b(m)(2)(A)(vi)(I) and §1396u-2(a)(4)(A)(ii)(I),a child (including an adolescent) enrolled under [drafter insert name of purchasing document] is entitled to disenroll without cause at any time during the 90-day period beginning upon receipt by the child of notice of enrollment.3 L(2) One-Year Period — Contractor agrees that, as authorized by §1932(a)(4)(A)(ii)(II) of the Social Security Act, 42 U.S.C. §1396u-2(a)(4)(A)(ii)(II),a child (including an adolescent) enrolled under [drafter insert name of purchasing document] is entitled to disenroll without cause every 12 months after receipt of the notice of enrollment under paragraph (1). K(3) Notice — Contractor shall notify, through the enrollee handbook given to the child (or to the child's family or caregiver) at the time of enrollment under §302(c)(12), each child and each child's family or caregiver of the child's right to disenroll without cause under paragraphs (1) and (2). K(c) Enrolled Child's Right to Disenroll for Cause —Upon request by an enrolled child (or a request by the child's family or caregiver with respect to the child), Contractor agrees that Purchaser has the authority and responsibility to disenroll the child under the circumstances enumerated in: (1) §401(d) (relating to inaccurate provider information); or (2) §401(e) (relating to no appropriate provider). K(d) Disenrollment Due to Loss of Eligibility — Contractor agrees that if an enrolled child is no longer eligible for [drafter insert name of State's Medicaid program]: (1) Purchaser has the authority and responsibility to terminate the enrollment of the child under [drafter insert name of purchasing document]; and (2) upon such disenrollment, Contractor shall comply with the requirements of §204(b). K(e) Disenrollment Without Cause — Contractor agrees that Purchaser has the authority and responsibility to disenroll an enrolled child (including an adolescent) without cause under the circumstances enumerated in: (1) subsection (b)(1) (relating to 90-day period); (2) subsection (b)(2) (relating to one-year period); (3) §1201(a)(3)(A) of Part 12 (relating to Contractor noncompliance); (4) §1201(a)(3)(B) of Part 12(relating to chronic substandard performance of Contractor); and (5) §1201(b) of Part 12 (relating to termination of [drafter insert name of purchasing document].
K§204. Duties Related to Children Receiving Treatment at the Time of Disenrollment Commentary: The following illustrative language addresses situations in which children are receiving acute care services at the time of disenrollment for a time-limited course of treatment. It is not intended to impose a duty on Contractors to continue the provision of services to disenrolled children with chronic care needs. Purchasers considering this language may also wish to consider adjusting their premium payments to reflect additional costs which Contractors may incur in complying with these duties. (a) Children Receiving Treatment at the Time of Voluntary Disenrollment — In the case of an enrolled child (including an adolescent) who, at the time of disenrollment for any reason other than the loss of eligibility for medical assistance, is under treatment for a particular diagnosis or condition, Contractor shall:4 (1) continue to cover and furnish, or arrange for the furnishing of, the acute care items or services in connection with such treatment, with no increase in cost-sharing obligations under §1003 of Part 10, until the earlier of the date on which: (A) the child is enrolled in a successor managed care plan; (B) Contractor has received notice from Purchaser that a fee-for-service provider has assumed responsibility for the treatment of the child; or (C) the child's treatment has been completed; (2) arrange at Contractor's expense for the transfer of the child's medical records to the successor managed care plan or provider assuming responsibility for care of the child within [ ] days of request by: (A) the child's family or caregiver; or (B) the successor managed care plan or provider; and (3) ensure that providers participating in Contractor's provider network who were furnishing care to the child at the time of disenrollment are: (A) notified of the child's disenrollment within [ ] days of the disenrollment; and (B) available for review of the child's treatment with the successor managed care plan or provider assuming responsibility. (b) Children Receiving Treatment at the Time of Involuntary Disenrollment — In the case of an enrolled child who is involuntarily disenrolled from Contractor under [drafter insert name of purchasing document] because of the loss of eligibility for [drafter insert name of State's Medicaid program] and who, at the time of involuntary disenrollment, is under treatment, Contractor shall: (1) ensure completion of the treatment;5 and (2) arrange (at Contractor's expense) for the transfer of the child's medical records to the successor managed care plan or provider assuming responsibility for care of the child within [ ] days of request by the child's family or caregiver or successor managed care plan or provider.
K§205. Duty Related to Children Not Receiving Treatment at Time of Involuntary Disenrollment (a) Basic Duty — In the case of an enrolled child who is involuntarily disenrolled from Contractor under [drafter insert name of purchasing document] because of the loss of eligibility for [drafter insert name of State's Medicaid program] and who, at the time of involuntary disenrollment, is not under treatment, Contractor shall arrange at Contractor's expense for the transfer of the child's medical records to the successor managed care plan or provider assuming responsibility for care of the child within [ ] days of request by: (1) the child's family or caregiver; or (2) the successor managed care plan or provider. KCompliance measure: Contractor shall make available to Purchaser upon request: (1) copies of all information furnished to network providers regarding responsibilities with respect to the treatment of newly enrolled and disenrolled children; (2) the names of children for whom records have been transferred following disenrollment, as well as the name of the successor managed care plan or provider receiving such records. Endnotes
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Reflected in this Part are provisions from the Balanced Budget Act of 1997 (BBA), P.L. 105-33 under §1932(a)(4) of the Social Security Act, 42 U.S.C. §1396u-2(a)(4) relating to enrollment and disenrollment procedures.
In a letter to State Medicaid Directors dated January 21, 1998 (www.hcfa.gov/medicaid/bbadisn.htm), HCFA notes that the BBA extends the enrollment period during which beneficiaries may be locked into a MCO to up to twelve months. In addition, the BBA provides for a 90-day period at the beginning of a beneficiary's enrollment during which he or she may disenroll without cause. The BBA further requires that beneficiaries be notified of their ability to disenroll or change plans at the end of their enrollment period at least 60 days before the end of that period. Finally, HCFA notes that beneficiaries are entitled to a 90-day "without cause" period for disenrollment any time they disenroll from one MCO and enroll in a different MCO, but not if they re-select the same MCO in which they had been enrolled.
If, as a purchaser, you are interested in buying pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language on enrollment and disenrollment procedures is for your consideration. Purchasers may also find it useful to review Negotiating the New Health System (3rd Ed.) which provides other options relating to enrollment and disenrollment procedures used by state agency purchasers in contracting with Medicaid MCOs. These options may be found at Table 1.2, Vol. 2, Part 1, pages 1-148 through 1-178; Table 1.3, Vol. 2, Part 1, pages 1-180 through 1-205; Table 1.4, Vol. 2, Part 1, pages 1-206 through 1-257; Table 1.7, Vol. 2, Part 1, pages 1-420 through 1-476 (www.gwu.edu/~chsrp).